Provider Demographics
NPI:1720074826
Name:O'DONNELL, PAT D (MD)
Entity Type:Individual
Prefix:
First Name:PAT
Middle Name:D
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 540
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 540
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112655208800000X
ARC-4788208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105046001Medicaid
IL036112655Medicaid
ILK14489Medicare PIN
IL256510Medicare PIN
B02384Medicare UPIN
IL036112655Medicaid